Influence of Preoperative Depressive Burden on Achieving a Minimal Clinically Important Difference Following Lumbar Decompression

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

This study evaluates the association of preoperative mental health with the rate of achieving minimal clinically important difference (MCID) in patient-reported outcomes following lumbar decompression (LD).

SUMMARY OF BACKGROUND DATA

Research is scarce regarding the influence of preoperative depression on the rate of achieving MCID for mental health, physical function, and pain among LD patients.

METHODS

A surgical registry was retrospectively reviewed for primary LD surgeries. Patients were grouped by depressive symptom severity according to the preoperative Patient Health Questionnaire 9 score. The association of Patient Health Questionnaire 9 subgroups with demographic and surgical variables was analyzed, and differences among subgroups were assessed. Achievement rates of MCID for physical function, pain, disability, and mental health were compared among groups at each time point using previously established MCID thresholds.

RESULTS

Of the 321 subjects, 69.8% were male, and 170 subjects had minimal preoperative depressive symptoms, 86 had moderate, and 65 had severe. Patients in moderate and severe groups demonstrated a significantly greater rate of MCID achievement for disability at 6 weeks and 3 months postoperatively. The severe group demonstrated a significantly higher rate of achieving MCID for mental health at the 1-year time point.

CONCLUSIONS

Patients with any range of preoperative depressive symptom severity had a similar rate of achieving MCID for pain and physical function throughout 1 year following LD. The severe depressive symptom group had a higher rate of MCID achievement with disability at 6 weeks and with mental health at 1 year. This study demonstrates that patients with any preoperative depressive symptom severity have an indistinguishable ability to attain MCID by 1 year following LD.

LEVEL OF EVIDENCE

Level III.

Prescription Patterns, Associated Factors, and Outcomes of Opioids for Operative Foot and Ankle Fractures: A Systematic Review

BACKGROUND

Pain management after foot and ankle surgery must surmount unique challenges that are not present in orthopaedic surgery performed on other parts of the body. However, disparate and inconsistent evidence makes it difficult to draw meaningful conclusions from individual studies.

QUESTIONS/PURPOSES

In this systematic review, we asked: what are (1) the patterns of opioid use or prescription (quantity, duration, incidence of persistent use), (2) factors associated with increased or decreased risk of persistent opioid use, and (3) the clinical outcomes (principally pain relief and adverse events) associated with opioid use in patients undergoing foot or ankle fracture surgery?

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for our review. We searched PubMed, Embase, Scopus, Cochrane, and Web of Science on October 15, 2021. We included studies published from 2010 to 2021 that assessed patterns of opioid use, factors associated with increased or decreased opioid use, and other outcomes associated with opioid use after foot or ankle fracture surgery (principally pain relief and adverse events). We excluded studies on pediatric populations and studies focused on acute postoperative pain where short-term opioid use (< 1 week) was a secondary outcome only. A total of 1713 articles were assessed and 18 were included. The quality of the 16 included retrospective observational studies and two randomized trials was evaluated using the Methodological Index for Non-Randomized Studies criteria and the Jadad scale, respectively; study quality was determined to be low to moderate for observational studies and good for randomized trials. Mean patient age ranged from 42 to 53 years. Fractures studied included unimalleolar, bimalleolar, trimalleolar, and pilon fractures.

RESULTS

Proportions of postoperative persistent opioid use (defined as use beyond 3 or 6 months postoperatively) ranged from 2.6% (546 of 20,992) to 18.5% (32 of 173) and reached 39% (28 of 72) when including patients with prior opioid use. Among the numerous associations reported by observational studies, two or more preoperative opioid prescriptions had the strongest overall association with increased opioid use, but this was assessed by only one study (OR 11.92 [95% confidence interval (CI) 9.16 to 13.30]; p < 0.001). Meanwhile, spinal and regional anesthesia (-13.5 to -41.1 oral morphine equivalents (OME) difference; all p < 0.01) and postoperative ketorolac use (40 OME difference; p = 0.037) were associated with decreased opioid consumption in two observational studies and a randomized trial, respectively. Three observational studies found that opioid use preoperatively was associated with a higher proportion of emergency department visits and readmission (OR 1.41 to 17.4; all p < 0.001), and opioid use at 2 weeks postoperatively was associated with slightly higher pain scores compared with nonopioid regimens (β = 0.042; p < 0.001 and Likert scale 2.5 versus 1.6; p < 0.05) in one study.

CONCLUSION

Even after noting possible inflation of the harms of opioids in this review, our findings nonetheless highlight the need for opioid prescription guidelines specific for foot and ankle surgery. In this context, surgeons should utilize short (< 1 week) opioid prescriptions, regional anesthesia, and multimodal pain management techniques, especially in patients at increased risk of prolonged opioid use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Opioid Use for Operative Foot and Ankle Fractures: A Systematic Review

Category:

Ankle; Trauma

Introduction/Purpose:

Patients treated operatively for foot and ankle fractures may be at higher risk of undertreated pain as well as overuse of opioid medications. We sought to synthesize the recent literature investigating use of opioids for analgesia following foot and ankle fracture surgery. To accomplish this, we aimed to determine the patterns of opioid use and prescription (e.g., quantity, duration, incidence of persistent use), risk or protective factors for persistent opioid use, and clinical outcomes (e.g., relief of pain, adverse events) associated with opioid use in this population.

Methods:

We followed PRISMA guidelines for our review. We systematically searched PubMed, Embase, Scopus, Cochrane, and Web of Science. We included studies published from 2010 to present that assessed patterns of opioid use, risk factors for increased opioid use, and outcomes associated with opioid use following foot/ankle fracture surgery. Two reviewers performed title/abstract screening and full-text review. The quality of included studies was evaluated using MINORS criteria.

Results:

In our review, 1713 articles were assessed and 18 were included (Figure 1). MINORS scores ranged from 13 to 18, indicating moderate study quality. Overall, there was wide variability in opioid use between and within studies. Rates of postoperative persistent opioid use ranged from 7-39%. Risk factors for increased opioid use included preoperative opioid exposure, mental health disorders, tobacco consumption, and certain injury patterns. Protective factors were spinal anesthesia, peripheral nerve block, and postoperative ketorolac. Opioid use was not associated with decreased pain or improved satisfaction. Opioid use was associated with increased rates of pain-related emergency department visits and readmission. Preoperative opioid use was associated with the greatest odds of increased postoperative use.

Conclusion:

There is a high incidence of persistent opioid use after foot and ankle fracture surgery. Opioid use was associated with negative health outcomes without decreasing pain levels or increasing patient satisfaction after foot/ankle fracture surgery. The wide variability of reported opioid use emphasizes the need for standardized guidelines for postoperative opioid use in this patient population, and our findings suggest that lower opioid prescription may be advisable.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure

BACKGROUND

Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs.

METHODS

Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ² test, logistic regression, and a t test. A P value <.05 was considered statistically significant.

RESULTS

There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls.

CONCLUSION

The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF).

SUMMARY OF BACKGROUND DATA

ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity.

METHODS

Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient.

RESULTS

A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades.

CONCLUSION

Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.

Validation of Veterans RAND 12-Item Physical Function Survey in Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND

Veterans RAND 12-item (VR-12) physical component score (PCS) has been validated in both veteran and US citizen populations; however, its use for spine surgery populations has not been evaluated. This study aims to correlate the VR-12 PCS survey with legacy patient-reported outcome measures (PROMs) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A prospective surgical database was retrospectively assessed for MIS TLIFs performed at 1 level from March 2015 to June 2019. Inclusion criteria were elective procedures for degenerative spinal pathology. Patients were excluded if they had surgery for metastatic, traumatic, or infectious etiologies or had incomplete preoperative 12-item Short Form (SF-12) PCS or Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) survey. Additionally, patients with any incomplete VR-12 PCS surveys through 1 year were excluded. Demographics and perioperative characteristics were recorded. Mean postoperative PROM scores and score difference from preoperative baseline were calculated at each postoperative timepoint through 1 year. The relationship of VR-12-PCS with SF-12-PCS and PROMIS PF was evaluated with a Pearson's correlation coefficient and time-independent partial correlation.

RESULTS

A total of 59 patients underwent single-level MIS TLIFs. The cohort was 44.1% women with an average age of 53.8 years, and 52.5% were obese (body mass index ≥30 kg/m2). The VR-12 PCS, SF-12 PCS, and PROMIS PF surveys had significant improvements from baseline to the 6 month through 1 year postoperative timepoints (P ≤ 0.001, all). All timepoints revealed strong VR-12-PCS correlations with SF-12-PCS and PROMIS PF (all P ≤ 0.001).

CONCLUSION

VR-12 PCS, SF-12 PCS, and PROMIS PF scores all indicate statistically significant improvements in physical function for patients following MIS TLIF. VR-12 PCS was strongly correlated with the historically validated SF-12 PCS system as well as with the more recent PROMIS PF survey. Our observations give weight to utilizing the VR-12 PCS survey as a valid measure of physical function among patients undergoing MIS TLIF.

CLINICAL RELEVANCE

This study validates VR-12 PCS to measure physical function for TLIF patients.

LEVEL OF EVIDENCE: 4

The Worldwide Influence of Social Media on Cervical Spine Literature

BACKGROUND

The Altmetric (Digital Science, Holtzbrinck Publishing) Attention Score (AAS) is an automatically calculated score that accounts for other literary influences, which include academic sources as well as nonacademically focused social media outlets such as Twitter, Facebook, and news articles. This study compares the most popular cervical surgery articles on social media to the most cited articles within peer-reviewed literature and identifies journals that contribute the most articles and geographic trends.

METHODS

We searched the Altmetric database for cervical spine surgery articles since inception using the search phrase "cervical" and "spine." We ranked journals that contributed the most articles and calculated their AAS, contributing social media outlets (eg, Twitter, Facebook, News, etc) and citation counts. We also ranked the top 100 most popular cervical spine articles on social media and compared them to the most cited articles. Countries were assessed based on their mentions through the most contributing social media platform.

RESULTS

Of the 527 total journals identified in our search, the top 10 journals were responsible for contributing 60.2% of the total articles. The 3 journals that contributed the most articles were Spine (18.9%), European Spine Journal (11.8%), and The Spine Journal (10.3%). The journals with the highest AAS scores included Journal of Neurosurgery: Spine (11.3), Spine (8.8), and Journal of Manipulative & Physiological Therapeutics (5.8). Social media outlets that contributed the most mentions per article were Twitter (4.4), Facebook (0.5), and news sources (0.3). Among all countries contributing Twitter mentions, the 3 countries with the most cervical spine posts included the United States (23.3%), the United Kingdom (10.3%), and Spain (5.5%).

CONCLUSION

Our evaluation of cervical spine literature revealed Twitter, Facebook, and news sources are the most common social media outlets influencing title dissemination. Journals contributing the most articles did not necessarily have the highest average AAS.

CLINICAL RELEVANCE

Spinal surgeons should consider utilization of social media outlets, such as Twitter, Facebook, and news sources, to potentially increase the dissemination of their articles.

LEVEL OF EVIDENCE: 3

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review

STUDY DESIGN

This was a systematic review study.

PURPOSE

This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC).

BACKGROUND

Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates.

METHODS

This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories.

RESULTS

Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092).

CONCLUSIONS

After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

Workers' Compensation Association With Clinical Outcomes After Anterior Cervical Diskectomy and Fusion

BACKGROUND

Research has suggested that workers' compensation (WC) status can result in poor outcomes after anterior cervical diskectomy and fusion (ACDF).

OBJECTIVE

To determine the influence WC status has on postoperative clinical outcomes after ACDF.

METHODS

A surgical database was reviewed for patients undergoing primary or revision single-level ACDF. Patients were grouped into WC vs Non-WC, and differences in baseline characteristics were assessed. Postoperative improvement was assessed for differences in mean scores between WC subgroups for visual analog scale (VAS) arm, VAS neck, 12-item Short Form Physical Composite Score, Patient-Reported Outcomes Measurement Information System physical function (PF), and Neck Disability Index (NDI) at preoperative and postoperative time points. Minimum clinically important difference (MCID) achievement was compared between groups.

RESULTS

The patient cohort included 44 with WC and 95 without. The cohort was 40% female with an average age of 48 years and mean body mass index of 30. Mean VAS arm, VAS neck, NDI, 12-item Short-Form Physical Composite Score, and Patient-Reported Outcomes Measurement Information System PF scores differed between groups; however, the difference was not sustained at the 1-yr time point. MCID achievement among WC subgroups was different for VAS arm (6 wk through 6 mo, P = .005), VAS neck (3 and 6 mo, P < .01), and NDI (3 and 6 mo, P < .05). No statistically significant difference was noted between cohorts for overall rates of MCID achievement for all patient-reported outcome measures collected.

CONCLUSION

WC patients reported similar preoperative and 1-yr postoperative neck and arm pain compared with non-WC patients after ACDF. One-yr MCID achievement rates were similar between cohorts for disability and PF scores.

Epidemiological Relevance of Elevated Preoperative Patient Health Questionnaire-9 Scores on Clinical Improvement Following Lumbar Decompression

BACKGROUND

Limited research exists regarding the influence of preoperative depression on postoperative mental health, physical function, and pain in lumbar decompression (LD) patients. This study aims to evaluate the association of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) with other mental health and physical function clinical outcomes among patients undergoing LD.

METHODS

A prospectively maintained surgical registry was reviewed for primary LD from March 2016 to May 2019. Patients were stratified into 3 preoperative PHQ-9 score subgroups. Higher PHQ-9 scores indicated greater depressive symptoms. We assessed demographic and perioperative characteristics among subgroups with appropriate statistical testing. We also evaluated outcome instruments and postoperative improvement for the following outcomes: PHQ-9, Short Form 12 (SF-12), Veterans RAND 12-Item (VR-12), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) leg, and VAS back.

RESULTS

The 351-subject cohort was 70.4% men with an average age of 47 years; 186 subjects had minimal preoperative depressive symptoms (PHQ-9 <5), 94 had moderate (5≤ PHQ-9 ≤10), and 71 had severe (PHQ-9 >10). Subgroups with more severe symptoms of depression had worse mental health outcome scores (PHQ-9, 12-Mental Health Composite Score [12-MCS], and VR-12-MCS) and a positive linear association with greater pre- to postoperative mental health improvements at all timepoints. Subgroups with more severe symptoms of depression had worse PROMIS-PF scores at all timepoints, though VAS pain scores had no depression symptom association by 1 year.

CONCLUSION

Patients with more severe preoperative depressive symptoms, as evaluated by PHQ-9, have a greater improvement in PHQ-9, SF-12, and VR-12 scores, but more severe PHQ-9 scores are associated with worse overall physical function scores. This study demonstrates the relevance of preoperative depressive symptoms and their necessity in future risk factor models.

CLINICAL RELEVANCE

Severity of preoperative PHQ-9 acts as a significant risk factor to postoperative pain and mental and physical health improvement.

Recovery of Physical Function Based on Body Mass Index Following Anterior Cervical Discectomy and Fusion

BACKGROUND

Body mass index (BMI) serves as a risk factor for complications and poorer outcomes following anterior cervical discectomy and fusion (ACDF). This study investigates the association between BMI and Patient Reported Outcomes Measurement Information System physical function (PROMIS-PF) following ACDF.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed for cervical spine surgeries between 2015 and 2019. Included patients underwent elective primary, single, or multilevel ACDF and were excluded for missing preoperative PROMIS-PF. Patients were stratified into 4 groups based on BMI score. Associations of demographic and perioperative characteristics with BMI groups were analyzed using either χ² test or t test. PROMIS-PF was evaluated preoperatively and 6 weeks, 12 weeks, 6 months, 1 year, and 2 years postoperatively using linear regression. Delta improvement in PROMIS-PF was evaluated at all time points.

RESULTS

The 128 study cohort had 74 patients the nonobese, 27 in the Obese I, 19 in the Obese II, and 8 in the Obese III groups. The mean age was 50.0 years and 57.0% were male. Gender, diabetic status, and Charlson Comorbidity Index (CCI) significantly differed by BMI groups but did not differ by perioperative characteristics. Preoperative PROMIS-PF did not significantly differ by group. Obese II and III groups had decreased PROMIS-PF compared to Obese I and nonobese groups at 1 year and 2 years. BMI groups had significantly different delta improvement at the 12 weeks (4.1 vs 10.1 vs 1.8 vs 4.3; P = 0.044) and 2 years (9.9 vs 7.1 vs 2.3 vs 3.0; P = 0.048).

CONCLUSION

Among the assessed BMI subgroups, all experienced similar physical function scores during the preoperative and short-term time points. Patients with higher BMI demonstrated diminished physical function at long-term time points. While this study focused on evaluating obesity, longitudinal tracking of high-risk patients during the postoperative period remains important for optimal rehabilitation.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

High BMI may predispose patients to lengthier recovery of physical function following ACDF.

Association of Preoperative Physical Function and Changes in Mental Health After Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND

Few investigations have focused on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores, patient depression measured by the Patient Health Questionnaire-9 (PHQ-9), and their relationship in the setting of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). This study aims to detail the association between preoperative physical function with postoperative change in physical function and in depressive symptoms.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to February 2019. Inclusion criteria were primary, single-level MIS TLIF procedures. Multilevel procedures and patients without PROMIS or PHQ-9 were excluded. Patients were grouped by preoperative PROMIS score (<35.0 and ≥35.0), with higher scores indicating greater physical function. A t test analyzed differences between PROMIS subgroups for operative time (skin incision to closure), estimated blood loss, length of stay, and discharge day. A t test also assessed the difference in PROMIS Physical Function (PF) and PHQ-9. Linear regression evaluated the relationship between pre- and postoperative PROMIS and PHQ-9.

RESULTS

Of 119 patients, 53.8% were male and 47.9% were obese. The mean ± SD age was 52.2 ± 10.7 years. The PROMIS <35.0 group had a larger improvement of PROMIS scores compared to the PROMIS ≥35.0 group at 6 weeks, 12 weeks, and 6 months. There was a negative association between preoperative PROMIS and PROMIS score improvement at 6 weeks, 12 weeks, and 6 months. For all time points, improvement in PHQ-9 was not associated with preoperative PROMIS scores.

CONCLUSION

From 0 weeks to 6 months after MIS TLIF, patients with lower preoperative physical function had larger improvements in PROMIS PF scores. Preoperative function was not predictive of postoperative changes in PHQ-9. While relationships between mental and physical health cannot be discounted, the lack of PHQ-9 association with physical function demonstrates the impact that MIS TLIF can have, regardless of PROMIS PF score.

CLINICAL RELEVANCE

Patients demonstrating lower levels of preoperative physical function may be in position for greater improvements in physical function following MIS TLIF surgery. In this study, there was no clear relationship between preoperative physical function levels and postoperative improvement in mental health, suggesting that all patients may achieve similar mental health improvement following MIS TLIF.

LEVEL OF EVIDENCE

3.

Preoperative Physical Function Association With Mental Health Improvement After Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective study.

OBJECTIVE

This study investigates the influence of physical function and their influence on postoperative depressive symptom scores as measured by Patient Health Questionnaire-9 (PHQ-9) among anterior cervical decompression and fusion (ACDF) patients.

BACKGROUND

While ACDF is one of the most commonly performed ambulatory surgeries, research is limited on the predictive value of Patient-Reported Outcomes Measurement Information System (PROMIS) scores and their influence on depressive symptoms as measured by the PHQ-9.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed from March 2016 to January 2019. Inclusion criteria were primary or revision ACDF procedures. Patients were grouped by preoperative PROMIS score (≥35.0, <35.0), with higher scores indicating greater physical function. The χ2 and Student t tests assessed categorical and continuous variables (eg, demographics, perioperative, and postoperative values). A t test evaluated postoperative improvement in PROMIS Physical Function (PF) scores between subgroups among PROMIS PF scores and PHQ-9 score improvement at 6, 12 weeks, 6 months, and 1 year. Linear regression assessed preoperative PROMIS scores influence on PHQ-9 score improvement.

RESULTS

The 121 subject cohort was 61.2% male with an average age of 49.6±9.8 years. Compared with the PROMIS ≥35.0 group, the PROMIS <35.0 group also had larger improvement of PROMIS scores at 6 weeks. No significant difference in postoperative PHQ-9 improvement was observed between subgroups. There was a negative association between preoperative PROMIS scores and improvement in PROMIS scores at 6, 12 weeks, 6 months, and 1 year. There was a positive association between preoperative PROMIS scores and magnitude of 1-year PHQ-9 change.

CONCLUSIONS

Individuals with lower preoperative PROMIS PF scores had significantly higher PHQ-9 scores at 1 year. Patients with lower preoperative physical function, as evaluated by PROMIS PF scoring, had greater improvement of mental health at 1 year postoperatively. This suggests that many patients experience multidimensional health benefits after ACDF procedures.

Readability Analysis of Patient-Accessible Information Regarding Ambulatory Surgical Center Procedures

BACKGROUND

As spine surgery in the ambulatory setting becomes more frequent, patients should comprehend the difference from traditional hospital-based, outpatient settings. Limited research exists on the readability of online articles surrounding spine surgery in the ambulatory surgery center (ASC). In this study, we intend to evaluate the readability of online articles pertaining to spine surgery in the outpatient and ambulatory surgical settings.

METHODS

Three search engines were queried, and the first 100 articles pertaining to each outpatient spine surgery search term were collected. Advertisements, videos, and peer-reviewed scientific articles were excluded. Articles were categorized by publishing source as follows: hospital or institution, general medical Websites, private practice, or surgery center. Flesch-Kincaid (FK) grade level, Flesch Reading Ease (FRE) score, word count, sentences per paragraph, words per sentence, and characters per word were evaluated for each article. Student's t tests compared readability metrics between groups based on setting and procedure region.

RESULTS

A total of 342 articles was analyzed; 279 articles were outpatient hospital related, and 63 ASC related. Flesch-Kincaid grade levels or FRE scores were not significantly different between outpatient hospital and ambulatory center. Comparison of ASC to outpatient articles from a hospital or institution source significantly differed in FRE score (40.7 versus 32.4) and FK grade level (12.3 versus 13.9; all P < .05). Articles addressing procedure type were significantly different in FRE score (36.2 versus 30.0) and FK grade level (13.0 ± 2.1 versus 14.3 ± 1.8).

CONCLUSIONS

Hospital, private practice, and medical journalists should be aware of significant differences in readability of patient-accessible ASC articles. These articles may be more difficult to read than outpatient hospital articles, and production of more reading-level-appropriate online literature is required.

LEVEL OF EVIDENCE

3 CLINICAL RELEVANCE: There is a significant difference in the readability of patient-accessible ASC articles.

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy

BACKGROUND

Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function.

METHODS

Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point.

RESULTS

Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years.

DISCUSSION

Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

The Influence of Comorbidity on Postoperative Outcomes Following Lumbar Decompression

STUDY DESIGN

Retrospective.

OBJECTIVE

Evaluate the association between comorbidity burden and reaching minimum clinically important difference (MCID) following lumbar decompression (LD).

SUMMARY OF BACKGROUND DATA

There is limited research on the influence of preoperative comorbidity burden on patient-reported outcome improvement following LD.

METHODS

A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries between 2015 and 2019. Inclusion criteria were primary, single, or multilevel LD. Patients were excluded for missing preoperative patient-reported outcome surveys. Stratification was based on Charlson Comorbidity Index (CCI) score: 0 points (no comorbidities), 1-2 points (low CCI), ≥3 points (high CCI). Demographics and perioperative characteristics were evaluated for differences. Linear regression assessed postoperative improvement for visual analogue scale (VAS) back, VAS leg, Oswestry disability index (ODI), Short Form-12 Physical Composite Score (SF-12 PCS), and Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) scores through 1 year. Achievement rate of MCID was compared between groups and evaluated for significant predictors.

RESULTS

Three hundred fourteen patients were included (123 no comorbidities, 100 low CCI, 91 high CCI). Higher CCI patients were older, more likely to smoke, and have comorbid diseases (all P<0.001). Perioperative differences included increased operative time, levels decompressed, length of stay, and discharge day in the CCI≥3 group. No differences in the rate of achieving MCID for VAS back, VAS leg, and ODI. CCI≥3 subgroup had a lower rate of reaching MCID at 6 months for SF-12 PCS, at 6 weeks for PROMIS-PF, and the overall rate for both SF-12 PCS and PROMIS-PF (all P<0.05). Multilevel procedures was a predictor for MCID achievement for ODI.

CONCLUSIONS

Patients with increased comorbidities undergoing LD had an equivalent MCID achievement rate for pain and disability metrics through 1 year. High CCI patients did, however, have a lower rate of achieving MCID for their physical function surveys which suggests that comorbidity burden influences improvement in physical function following LD.

Multimodal Analgesic Management for Lumbar Decompression Surgery in the Ambulatory Setting: Clinical Case Series and Review of the Literature

BACKGROUND

Effective pain control is vital for successful surgery in the ambulatory setting. Our study aims to characterize a case series of patients who underwent lumbar decompression (LD) in the ambulatory surgical center (ASC) with the use of a multimodal analgesic (MMA) protocol.

METHODS

A prospective surgical registry was retrospectively assessed for patients who underwent single or multilevel LD in an ASC using MMA from 2013 to 2019. Observation in excess of 23 hours was not permitted at the ASC, and patients were required to be discharged the same day. Length of stay, patient-reported visual analog scale pain scores before discharge, and the quantity of narcotic medications administered to patients before discharge were recorded. Quantity of narcotic medications were converted into units of oral morphine equivalents and summed across all types of narcotic medications prescribed.

RESULTS

A total of 499 patients were included. In total, 86.0% (429) of the patients underwent a single-level decompression procedure, 13.8% (69) of patients underwent a 2-level, and 0.2% (1) of the patients underwent a 3-level procedure; 83.6% (417) of the patients in this study underwent a primary LD, and 14.0% (70) underwent a revision decompression.

CONCLUSIONS

This is the largest clinical case series focused on LD procedures within an ASC requiring no planned 23-hour observation. This study demonstrates the feasibility of performing LD surgery in an ASC with proper patient selection, surgical technique, and MMA protocol. All patients were discharged from the surgical center on the same day of surgery.

The Influence of Sex on Clinical Outcomes in Minimally Invasive Lumbar Decompression

BACKGROUND

Research focused on postoperative outcomes among men and women undergoing minimally invasive lumbar decompression (MIS LD) spine surgery is sparse. This study aims to assess the influence of sex on postoperative patient-reported outcome measure (PROM) evaluations and achievement of a minimum clinically important difference (MCID).

METHODS

A prospectively maintained surgical database was retrospectively queried for patients undergoing primary or revision, single or multilevel LD procedures from 2011 to 2019. Patients with incomplete visual analog scale (VAS) leg or back surveys were excluded. Demographic and operative variables were recorded, and a chi-squared analysis or t tests were used to compare by sex. PROMs were evaluated from preoperative to postoperative time points. PROM score differences and postoperative improvement were evaluated between sexes by a t test. Achievement of MCID by sex was compared using chi-squared analysis.

RESULTS

The study cohort (n = 572) was 70% male (n = 398), had an average age of 47 years, and 42% were obese. Sexes differed in preoperative VAS leg, Oswestry Disability Index (ODI), and 12-item short form (SF-12)-physical composite score (PCS) scores (all P < .05) and in ODI at 6 and 12 weeks (P = .048; P = .001) and VAS back and leg scores at 6 months (P = .039; P = .019). Both sexes significantly improved (P < .050) all PROMs at all time points except for VAS back at 1 year for women and ODI at 6 weeks and 6 months for men. The only significant difference in achievement of MCID was for ODI at 6 months (P = .008).

CONCLUSIONS

Significant preoperative differences were observed among sexes with ODI, SF-12-PCS, and VAS leg scores. By 1 year, there were no significant sex differences for any PROM or for achievement of MCID. MIS LD has an equivalent role for both sexes in achieving MCID.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Results demonstrate no sex difference in PROMs following LD.

Charlson Comorbidity Index: An Inaccurate Predictor of Minimally Invasive Lumbar Spinal Fusion Outcomes

BACKGROUND

There is a scarcity of research on the Charlson Comorbidity Index (CCI) and its influence on minimum clinically important difference (MCID) achievement after minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF). The objective of this study is to detail the association between the CCI and attaining MCID after MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between May 2015 and February 2019. Inclusion criteria were primary or revision, 1- or 2-level MIS TLIF procedures. Patients were stratified based on CCI score: 0 points (no comorbidities), 1-2 points (mild CCI), ≥3 points (moderate CCI). Preoperative, intraoperative, and postoperative variables were assessed by subgroup using appropriate statistical analysis. Subgroups were analyzed with linear regression or χ² tests for continuous or categorical variables, respectively. Subgroup scores, improvement, and MCID achievement were assessed at postoperative timepoints (eg, 6 weeks, 12 weeks, 6 months, and 1 year) for back and leg pain, Oswestry Disability Index (ODI), SF-12 Physical Composite Score (PCS), and Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF).

RESULTS

A total of 171 patients were included (n = 51 [no comorbidities], n = 73 [mild CCI], and n = 47 [moderate CCI]). Higher CCI patients were older and more likely to be smokers, diabetic, arthritic, hypertensive, or have a malignancy history (P < 0.003). Preoperatively, ODI and PROMIS PF were the only patient-reported outcomes with a significant association by CCI group (P = 0.015 and 0.014). Back pain was the only measure that had a significant association with the CCI subgroup at 1 year for score (P = 0.002) or MCID (P = 0.028).

CONCLUSIONS

By 1 year, regardless of the number of comorbidities, a similar proportion of patients undergoing MIS TLIF were able to achieve MCID for visual analog scale leg, SF-12 PCS, and PROMIS PF. Patients with higher comorbidities are not likely to experience a significant difference in symptom improvement. Regardless of CCI score, MIS TLIF can have a significant benefit for patients.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Text.

Patient Health Questionnaire-9 Is a Valid Assessment for Depression in Minimally Invasive Lumbar Discectomy

Objective

The Patient Health Questionnaire-9 (PHQ-9) is a screening tool for evaluating depressive symptoms. Research is scarce regarding the validity and correlation of PHQ-9 scores with other patient-reported outcomes of mental health after minimally invasive lumbar discectomy (MIS LD). We aim to validate PHQ-9 as a metric for assessing mental health in MIS LD patients.

Methods

A database was retrospectively reviewed for patients who underwent elective, single-level MIS LD. Patients were excluded if they had incomplete preoperative PHQ-9, 12-item Short Form Health Survey (SF-12), or Veterans RAND 12-item health survey (VR-12). Survey scores were collected preoperatively and postoperatively through 1 year. Mean scores were used to calculate postoperative improvement from preoperative scores. Correlation of PHQ-9 with SF-12 mental composite score (MCS) and VR-12 MCS scores was also calculated. Correlation strength was assessed by the following categories: 0.1 ≤ |r| < 0.3 = low; 0.3 ≤ |r| < 0.5 = moderate; |r| ≥ 0.5 = strong.

Results

A total of 239 patients underwent single-level MIS LD. PHQ-9, VR-12 MCS, and SF-12 MCS all demonstrated statistically significant increases from preoperative scores at all postoperative timepoints (p ≤ 0.001). SF-12 MCS and VR-12 MCS were each observed to have strong and significant correlations with PHQ-9 at all timepoints when evaluated with both Pearson correlation coefficients and partial correlation coefficients.

Conclusion

We observed that PHQ-9, SF-12 MCS and VR-12 MCS all significantly improve following lumbar discectomy and that PHQ-9 scores strongly correlated with these previously established measures. Our results substantiate evidence from other surgical fields that PHQ-9 scores are a valid tool to evaluate pre- and postsurgical depressive symptoms.

The Influence of Opioid Use Disorder on Open Reduction and Internal Fixation Following Ankle Fracture

BACKGROUND

Ankle fractures are common and may require open reduction and internal fixation (ORIF). Literature is scarce evaluating the associations of opioid use disorder (OUD) with ORIF postoperative outcomes. This study investigates whether OUD patients have increased (1) costs of care, (2) emergency room visits, and (3) readmission rates.

METHODS

ORIF patients with a 90-day history of OUD were identified using an administrative claims database. OUD patients were matched (1:4) to controls by age, sex, and medical comorbidities. The Welch t-test determined the significance of cost of care. Logistic regression yielded odds ratios (ORs) for emergency room visits and 90-day readmission rates.

RESULTS

A total of 2183 patients underwent ORIF (n = 485 with OUD vs n = 1698 without OUD). OUD patients incurred significantly higher costs of care compared with controls ($5921.59 vs $5128.22, P < .0001). OUD patients had a higher incidence and odds of emergency room visits compared with controls (3.50% vs 0.64%; OR = 5.57, 95% CI = 2.59-11.97, P < .0001). The 90-day readmission rates were not significantly different between patients with and without OUD (8.65% vs 7.30%; OR = 1.20, 95% CI = 0.83-1.73, P = .320).

CONCLUSION

OUD patients have greater costs of care and odds of emergency room visits within 90 days following ORIF.Levels of Evidence: Level III: Retrospective cohort study.

The Minimum Clinically Important Difference for Patient Health Questionnaire-9 in Minimally Invasive Transforaminal Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To investigate and establish minimum clinically important differences (MCID) for Patient Health Questionnaire-9 (PHQ-9) among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND

Spine surgery is linked to postoperative improvements in anxiety, depression, and mental health. These improvements have been documented using patient-reported outcome measures such as PHQ-9. Few studies evaluated the clinical significance of PHQ-9 for lumbar spine surgery.

METHODS

Patients who underwent single-level, primary MIS TLIF from 2015 to 2017 were retrospectively reviewed in a prospective database. Patients with incomplete preoperative and 2-year postoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded. PHQ-9, 12-Item Short Form (SF-12), and Veterans RAND 12-Item Health Survey (VR-12) Mental Component Summary (MCS) were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year intervals. MCID was calculated using anchor and distribution-based methods. SF-12 served as an anchor. MCID was assessed using mean change methodology, four receiver operating characteristic curve assessments, and standard error measurement. Cutoff values were selected from receiver operating characteristic curve analysis. MCID achievement rates for all patient-reported outcome measures were calculated.

RESULTS

A total of 139 patients met inclusion criteria, with a mean age of 55 years and 39% females. The most common spinal pathology was radiculopathy (92%). MCID analysis revealed the following ranges of values: 2.0 to 4.8 (PHQ-9), 6.7 to 12.1 (SF-12 MCS), and 7.5 to 15.9 (VR-12 MCS). Final MCID thresholds were 3.0 (PHQ-9), 9.1 (SF-12 MCS), and 8.1 (VR-12 MCS). MCID achievement at 2-years for PHQ-9, SF-12 MCS, and VR-12 MCS was 89.2%, 85.6%, and 84.9% respectively.

CONCLUSION

Our 2-year postoperative MCID analysis is the first mental health calculation from an MIS TLIF cohort. We report a 2-year MCID value for PHQ-9 of 3.0 (2.0-4.8). MCID values for mental health instruments are important for determining overall success of lumbar spine surgery.Level of Evidence: 3.

Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting

BACKGROUND

Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol.

METHODS

A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered.

RESULTS

A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day.

CONCLUSION

In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

Role of Gender in Improvement of Depressive Symptoms Among Patients Undergoing Cervical Spine Procedures

OBJECTIVE

There is a scarcity of research evaluating gender differences in depressive symptoms among patients undergoing cervical surgery. This study investigated gender differences with regard to depressive symptom severity, measured by Patient Health Questionnaire-9 (PHQ-9), in patients following anterior cervical discectomy and fusion (ACDF) or artificial disc replacement (ADR).

METHODS

A prospectively maintained surgical registry was retrospectively reviewed for eligible spine surgeries. Depressive symptom severity was evaluated by PHQ-9 at both preand postoperative timepoints (e.g. , 6 weeks, 12 weeks, 6 months, 1 year, and 2 years). A chi-square test and Student t-test evaluated differences between the gender for demographic and operative variables where appropriate. Differences between the gender subgroup mean PHQ-9 scores were assessed using a t-test pre- and postoperatively (e.g. , 6 weeks, 12 weeks, 6 months, and 1 year) and a paired t-test was used to assess differences from preoperative scores at each postoperative time point.

RESULTS

A total of 170 subjects underwent 125 ACDFs and 45 ADRs. Both pre- and postoperative timepoints demonstrated no significant differences between mean PHQ-9 scores by gender. Female patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, and 12 weeks, but not through 2 years. Male patients demonstrated statistically significant improvement in PHQ-9 scores at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years.

CONCLUSION

Although there were no significant differences between mean PHQ-9 score between the genders, there was a difference in magnitude of improvement. Females had a significant improvement in depressive symptom severity over baseline at the 6- and 12-week timepoints only, whereas males had significant improvement through 2 years postoperatively.

Patient-Reported Outcomes Measurement Information System Physical Function Validation for Use in Anterior Cervical Discectomy and Fusion: A 2-Year Follow-up Study

Objective

Our study aims to evaluate the correlation of Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) with legacy patient-reported outcome measures (PROMs) among patients undergoing anterior cervical discectomy and fusion (ACDF).

Methods

A prospectively maintained database was retrospectively reviewed for ACDF surgeries performed between May 2015 and September 2017. Inclusion criteria were primary elective, single- or multilevel ACDFs for degenerative spinal pathology. Patients lacking preoperative or 2-year PROMIS PF surveys were excluded. Mean scores were calculated for visual analogue scale (VAS) neck, VAS arm, Neck Disability Index (NDI), 12-Item Short Form Physical Component Score (SF-12 PCS), and PROMIS PF at preoperative and 6-week, 12-week, 6-month, 1-year, and 2-year postoperative timepoints. A t-test and Pearson correlation coefficient were utilized to evaluate score improvement and PROM relationships respectively.

Results

The 50 subject cohort was 60.0% male, 50% obese (body mass index ≥ 30 kg/m²) and had an average age of 50.9 years. Significant improvements were demonstrated for VAS neck and NDI at all postoperative timepoints (p < 0.001) and for SF-12 and PROMIS PF at all timepoints except 6 weeks (p ≤ 0.025). VAS arm improvement was seen up to 1 year (p ≤ 0.016). PROMIS PF demonstrated strong correlations with NDI and SF-12 PCS at all evaluated timepoints and with VAS neck at all postoperative timepoints except 6 weeks (all p < 0.01).

Conclusion

PROMIS PF was strongly correlated with pain, disability, and physical function up to 2 years for patients undergoing ACDF. Our results support the long-term validity of PROMIS PF for measurement of patient-reported physical function among ACDF cohorts.

The influence of cognitive behavioral therapy on lumbar spine surgery outcomes: a systematic review and meta-analysis

PURPOSE

As more patients undergo lumbar spine surgery, novel interventions may improve physical and mental health outcomes. Few studies summarize the benefit of cognitive behavioral therapy (CBT) among lumbar spine surgery patients. This study collects randomized control trial data to investigate the influence of CBT on patient reported outcomes among lumbar spine surgery patients.

METHODS

Our study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and a medical library expert assisted in searching PubMed/MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, and Google Scholar. We calculated standardized mean differences (SMD) to evaluate the effect size of CBT versus control groups with a sensitivity analysis.

RESULTS

Our meta-analysis included seven studies with a total of 531 patients. The majority of included studies evaluated lumbar fusion, with preoperative CBT performed by physiotherapists. The largest effects were observed for overall quality of life (SMD = 0.55 [95% CI 0.05, 1.05], p < 0.001, I² = 86.7%) and psychological outcomes (SMD = 0.61 [95% CI 0.28, 0.94], p < 0.001, I² = 89.7%) though disability and pain outcomes also favored CBT intervention. Included studies demonstrated low overall bias but large heterogeneity. Sensitivity analysis demonstrated negligible study design differences and revealed moderators including CBT session frequency and final follow-up duration (p < 0.001).

CONCLUSION

Compared to usual care or alternative therapy control arms, CBT delivered the most improvement with overall quality of life and psychological outcomes. Among appropriately selected patients, CBT could improve perioperative disability, pain, quality of life, and psychological health following lumbar spine surgery.

The Perioperative Symptom Severity of Higher Patient Health Questionnaire-9 Scores Between Genders in Single-Level Lumbar Fusion

BACKGROUND

Preoperative depression is associated with increased perioperative pain, worse physical function, reduced quality of life, and inferior outcomes. Few studies have evaluated depressive symptoms between genders for individuals undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this investigation was to assess the severity of Patient Health Questionnaire-9 (PHQ-9) scores among patients with depressive symptoms before and after single-level MIS TLIF.

METHODS

A prospective surgical registry was retrospectively reviewed for spine surgeries between March 2016 and December 2018. We included patients with at least mild depressive symptoms (PHQ-9 scores ≥ 5) who underwent primary, single-level MIS TLIF and compared genders using χ2 tests and t tests. Genders were stratified by depressive symptom severity: mild (5-9), moderate (10-14), and moderately severe (≥15) and then analyzed at preoperative and postoperative intervals: 6 weeks, 12 weeks, 6 months, and 1 year. Finally, PHQ-9 scores were validated with a Pearson correlation test against the 12-item Short Form (SF-12) Mental Composite Score (MCS) and the Veterans RAND (VR-12) MCS.

RESULTS

Of 75 subjects, 44.0% were women and the mean age was 49.9 years. The preoperative distribution among PHQ-9 subgroups was 38.7%, 26.6%, and 34.7% for mild, moderate, and moderately severe depressive symptoms, respectively. Among PHQ-9 stratifications both genders demonstrated intermittent statistically significant improvements in PHQ-9 scores. The moderately severe PHQ-9 subgroup had improvement at all postoperative time points. The PHQ-9 scores demonstrated a strong correlation with the SF-12 MCS and VR-12 MCS at all postoperative evaluations.

CONCLUSION

At baseline and by the final 1-year follow-up there were no statistically significant PHQ-9 score differences between genders within any depressive symptom stratifications. Whereas some contend that men and women have substantial mental health differences, this study is aligned with growing evidence that demonstrates similar depressive symptoms between genders.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Men and women may be at an equivalent risk for perioperative depressive symptoms.

Intraoperative risks of radiation exposure for the surgeon and patient

Intraoperative radiological imaging serves an essential role in many spine surgery procedures. It is critical that patients, staff and physicians have an adequate understanding of the risks and benefits associated with radiation exposure for all involved. In this review, we briefly introduce the current trends associated with intraoperative radiological imaging. With the increased utilization of minimally invasive spine surgery (MIS) techniques, the benefits of intraoperative imaging have become even more important. Less surgical exposure, however, often equates to an increased requirement for intraoperative imaging. Understanding the conventions for radiation measurement, radiological fundamental concepts, along with deterministic or stochastic effects gives a framework for conceptualizing how radiation exposure relates to the risk of various sequela. Additionally, we describe the various options surgeons have for intraoperative imaging modalities including those based on conventional fluoroscopy, computer tomography, and magnetic resonance imaging. We also describe different ways to prevent unnecessary radiation exposure including dose reduction, better education, and use of personal protective equipment (PPE). Finally, we conclude with a reflection on the progress that has been made to limit intraoperative radiation exposure and the promise of future technology and policy.

Longitudinal Evaluation of Patient-Reported Outcomes Measurement Information System for Back and Leg Pain in Minimally Invasive Transforaminal Lumbar Interbody Fusion

OBJECTIVE

While visual analogue score (VAS) metrics are among the most universally adopted patient-reported outcome measures (PROMs), there is limited research on the influence of back and leg pain on the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores. Here we assess the association of VAS back and VAS leg scores with PROMIS PF in the setting of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Secondarily, we determine if PROMIS PF is more influenced by back or leg pain.

METHODS

A prospective surgical registry was reviewed from May 2015 to November 2018. Inclusion criteria were primary, single-level MIS TLIFs. We excluded multilevel procedures and patients without preoperative PROMs. Pre- and postoperative PROMIS PF, VAS back, and VAS leg scores were recorded at 6 weeks, 12 weeks, 6 months, and 1 year. A Pearson correlation evaluated PROMIS PF association with VAS back and VAS leg scores. A Fisher z-test compared correlations. Linear regression evaluated PROMIS with VAS back and VAS leg scores.

RESULTS

Our cohort was comprised of 146 subjects. 40.4% were female and the average age of 51 years. VAS back demonstrated a stronger correlation than VAS leg with PROMIS PF at all timepoints. PROMIS PF scores were negatively associated with both VAS back and VAS leg at all timepoints. Fisher z-test revealed VAS back to have a stronger correlation with PROMIS PF (p = 0.025) than VAS leg.

CONCLUSION

In the setting of MIS TLIF, physical function as evaluated by PROMIS PF, had a stronger correlation with VAS back than VAS leg at 6 months. This suggests that postoperative PROMIS PF scores may be more influenced by back pain than with leg pain.

Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting

BACKGROUND

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.

METHODS

Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.

RESULTS

Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.

CONCLUSIONS

The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Does day of surgery affect length of stay and hospital charges following lumbar decompression?

Study Design:

This is a retrospective cohort study.

Introduction:

Spine procedures are the most expensive surgical interventions on a per-case basis. Previously, orthopedic procedures occurring later in the week have been associated with an increased length of stay (LOS) and consequent increase in costs. However, no such analysis has been performed on common spinal procedures such as minimally invasive lumbar decompression (MIS LD). The purpose of this study is to determine if there is an association between day of surgery and LOS or direct hospital costs after MIS LD.

Materials and Methods:

A prospectively maintained surgical database of patients who underwent primary, single, or multilevel MIS LD for degenerative spinal pathology between 2008 and 2017 was reviewed. Patients undergoing MIS LD were grouped as early in the week (Monday/Tuesday) or late in the week (Thursday/Friday). Differences in patient demographics and preoperative characteristics were compared using χ 2 analysis or Student’s t-test. Associations between date of surgery, LOS, and costs were assessed using multivariate linear regression.

Results:

A total of 717 patients were included. Of these, 420 (58.6%) were in the early surgery cohort and 297 (41.4%) were in the late surgery cohort. There were no differences in demographic characteristics, operative levels, operative time, blood loss, or hospital LOS between cohorts ( p > 0.05). Furthermore, there was no difference in total direct costs or specific cost categories between cohorts ( p > 0.05).

Discussion:

The timing of surgery within the week is not associated with differences in inpatient LOS or hospital costs following MIS LD. As such, hospitals should not alter surgical scheduling patterns to restrict these procedures to certain days within the week.

Validating the VR-12 Physical Function Instrument After Anterior Cervical Discectomy and Fusion with SF-12, PROMIS, and NDI

BACKGROUND

Development and validation of Veterans RAND 12-item (VR-12) physical component survey (PCS) has been established among civilian and veteran populations but it has not been examined among anterior cervical discectomy and fusion (ACDF) patients.

PURPOSES/QUESTIONS

We sought to validate legacy patient-reported outcome measures (PROMs) with VR-12 PCS among patients undergoing ACDF procedures.

METHODS

A prospectively collected surgical registry was retrospectively evaluated for elective single or multi-level ACDFs performed for degenerative spinal pathologies from January 2014 to August 2019. Exclusion criteria included missing pre-operative surveys and surgery for trauma, metastasis, or infection. Demographic variables, baseline pathologies, and peri-operative variables were collected. A paired t test evaluated the change from the pre-operative score to each post-operative timepoint for VR-12 PCS, the 12-item Short-Form Survey (SF-12) PCS, Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF), and Neck Disability Index (NDI). Minimal clinically important difference (MCID) achievement was calculated at each timepoint. Correlation was evaluated with a Pearson's correlation coefficient and time-independent partial correlation.

RESULTS

Of the 202 patients who underwent ACDF, 41.1% were female and the average age was 49.5 years. All PROMs had statistically significantly increased from baseline when compared with post-operative timepoints (12 weeks, 6 months, 1 year, and 2 years). MCID achievement rates increased through 2 years. All timepoints revealed strong VR-12 PCS correlations with SF-12 PCS, PROMIS-PF, and NDI scores.

CONCLUSION

VR-12 PCS was strongly correlated with the well-validated SF-12 PCS and NDI metrics as well as with the more recent PROMIS-PF. All PROMs demonstrated statistically significant improvement in patients post-operatively. VR-12 PCS is a valid measure of physical function among patients undergoing ACDF.

Improvements in Back and Leg Pain Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND

Improvement in patient-reported outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is poorly defined. As such, the purpose of this study was to quantify improvements in Visual Analogue Scale back and leg pain, Oswestry Disability Index (ODI), and Short Form-12 (SF-12) Mental and Physical Composite scores following MIS-TLIF.

METHODS

A surgical registry of patients who underwent primary 1-level MIS-TLIF during 2014-2015 was reviewed. Comparisons of Visual Analogue Scale back and leg pain, ODI, and Short Form-12 Mental and Physical Composite scores were performed using paired t tests from preoperative to each postoperative time point. Analysis of variance was used to estimate the degree of improvement in back and leg pain over the first postoperative year. Subgroup analysis was performed for patients presenting with predominant back (pBP) or leg (pLP) pain. Multivariate linear regression was performed to compare patient-reported outcome scores by subgroup.

RESULTS

A total of 106 patients were identified. Visual Analogue Scale back and leg scores, and ODI improved from preoperative scores at all postoperative time points (P < .05 for each). Patients with pBP (n = 68) and patients with pLP (n = 38) reported reductions in both back and leg pain over the first postoperative year (P < .05 for each). In the pBP cohort, patients experienced significant reductions in ODI after the first 6 postoperative weeks (P < .05 for each). In the pLP cohort, patients experienced significant reductions in ODI throughout the first postoperative year (P < .05 for each). Patients with pLP and pBP experienced similar reductions in back pain, whereas patients with pLP experienced significantly greater reductions in leg pain at all postoperative time points (P < .05 for each).

CONCLUSIONS

The current study suggests patients experience significant improvements in back and leg pain following MIS-TLIF regardless of predominant symptom.

CLINICAL RELEVANCE

These results can assist surgeons when counseling their patients on the magnitude of symptom improvement they may experience following MIS-TLIF.

Postoperative Pain, Narcotics Consumption, and Patient-Reported Outcomes Based on PROMIS Physical Function Following a Single-Level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective.

OBJECTIVE

To determine the association between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) scores with postoperative pain, narcotics use, and patient-reported outcomes (PRO) following a single-level anterior cervical discectomy and fusion (ACDF) procedure.

SUMMARY OF BACKGROUND DATA

There is a scarcity of prior literature on the ability of baseline PROMIS scores to predict clinical outcomes for patients undergoing ACDF procedures.

METHODS

Patients who underwent a primary ACDF were retrospectively reviewed and stratified into low and high disability cohorts. Preoperative PROMIS PF cohorts were tested for association with demographic and perioperative characteristics using chi-square analysis and one-way analysis of variance. Cohorts were tested for association with inpatient pain scores and narcotics consumption, as well as postoperative improvements in PROMIS PF, neck disability index (NDI), and visual analog scale (VAS) neck and arm pain using linear regression.

RESULTS

Ninety one patients were included: 39 low disability and 52 high disability. Inpatient postoperative VAS pain scores and narcotic consumption are also compared between cohorts. Patients with greater disability reported higher VAS pain scores (P = 0.003). However, patients in both cohorts consumed comparable amounts of narcotics (P = 0.926). Patients with greater preoperative disability demonstrated lower PROMIS PF scores, greater NDI scores, and greater VAS Neck scores at the preoperative baseline. However, patients demonstrated similar improvement of VAS neck and arm pain, as well as NDI at all postoperative timepoints. Patients with low disability reported worsened physical function at the 6 weeks timepoint.

CONCLUSION

Patients with worse preoperative disability as measured by PROMIS PF reported increased pain but comparable narcotics consumption in the immediate postoperative period following a single-level ACDF procedure. Furthermore, patients experienced similar long-term postoperative improvement of PROs regardless of preoperative physical function. PROMIS PF can efficiently quantify physical function before and after the ACDF procedure as self-evaluated by patients.

LEVEL OF EVIDENCE

3.

A Review of Vitamin D in Spinal Surgery: Deficiency Screening, Treatment, and Outcomes

In this review, we discuss the demonstrated value of vitamin D in bone maintenance, fracture resistance, spinal health, and spine surgery outcomes. Despite this, the effect of vitamin D levels in spine surgery has not been well described. Through this review of literature, several conclusions were drawn. First, despite the fact that a high number of spine surgery patients are vitamin D deficient, screening is not commonly performed. Second, adequate vitamin D levels will not be achieved in a majority of these patients without supplementation. Last, inadequate vitamin D levels may increase the risk of pseudarthrosis. Given these findings, we suggest that many patients undergoing spinal surgery could be treated with vitamin D supplementation prior to surgery without the need for confirmatory testing for vitamin D deficiency. This is a more cost-effective method than screening all patients. However, future randomized trials and cost-effectiveness analyses are needed to determine the ultimate effects of vitamin D supplementation on clinical morbidity and surgical outcomes.

Association of Preoperative PROMIS Scores With Short-term Postoperative Improvements in Physical Function After Minimally Invasive Transforaminal Lumbar Interbody Fusion

Objective

This study examines the associations between preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) score, measured by PROMIS-PF and the change between pre- and postoperative PROMIS-PF scores.

Methods

A prospectively maintained surgical registry was retrospectively reviewed for spine surgeries between May 2015–June 2019. Inclusion criteria were primary, single-level minimally invasive transforaminal lumbar interbody fusions. Revisions, multilevel procedures, and patients missing preoperative surveys were excluded. Patients were grouped by preoperative PROMIS-PF scores of ≥ 35 and < 35, with higher scores indicating greater PF. A chi-squared and Student t-test were used to analyze categorical and continuous variables respectively. Linear regression evaluated the relationship of PROMIS-PF score improvement.

Results

Of the 180 subjects, 84 were in the PROMIS-PF < 35 group which had more obese patients (p < 0.001) and more males (p = 0.001). Length of stay was greater for the PROMIS-PF < 35 group (36.2 hours vs. 28.7 hours, p = 0.014). PROMIS-PF and Oswestry Disability Index scores were significantly different between subgroups at all timepoints. PROMIS-PF < 35 cohort had larger postoperative PROMIS-PF improvements at 6 weeks (p = 0.008) and 12 weeks (p = 0.003). Linear regression demonstrated a negative association between preoperative PROMIS-PF scores and improvement at 6 weeks, 12 weeks, 6 months, and 2 years (p < 0.001). PROMIS-PF < 35 demonstrated significantly lower rate of achieving minimum clinically important difference at 6 months, otherwise no difference observed throughout the 2-year follow-up.

Conclusion

Up to 6 months postoperatively, lower preoperative PROMIS-PF scores were associated with larger PROMIS-PF improvements. Understanding the relationship preoperative PROMIS-PF scores have with postoperative improvement may enable better patient counseling.

Predictors of inpatient admission in the setting of anterior lumbar interbody fusion: a Minimally Invasive Spine Study Group (MISSG) investigation

OBJECTIVE

While the anterior lumbar interbody fusion (ALIF) procedure may be amenable to ambulatory surgery, it has been hypothesized that limitations such as the risk of postoperative ileus and vascular complications have hindered transition of this procedure to the outpatient setting. Identification of independent risk factors predisposing patients to inpatient stays of ≥ 24 hours after ALIF may facilitate better postsurgical outcomes, target modifiable risk factors, and assist in the development of screening tools to transition appropriate patients to the ambulatory surgery center (ASC) setting for this procedure. The purpose of this study was to identify the most relevant risk factors that predispose patients to ≥ 24-hour admission following ALIF.

METHODS

A prospectively maintained surgical registry was reviewed for patients undergoing single ALIF between May 2006 and December 2019. Demographics, preoperative diagnosis, perioperative variables, and postoperative complications were evaluated according to their relative risk (RR) elevation for an inpatient stay of ≥ 24 hours. A Poisson regression model was used to evaluate predictors of inpatient stays of ≥ 24 hours. Risk factors for inpatient admission of ≥ 24 hours were identified with a stepwise backward regression model.

RESULTS

A total of 111 patients underwent single-level ALIF (50.9% female and 52.6% male, ≤ 50 years old). Eleven (9.5%) patients were discharged in < 24 hours and 116 remained admitted for ≥ 24 hours. The average inpatient stay was > 2 days (53.7 hours). The most common postoperative complications were fever (body temperature ≥ 100.4°F; n = 4, 3.5%) and blood transfusions (n = 4, 3.5%). Bivariate analysis revealed a preoperative diagnosis of retrolisthesis or lateral listhesis to elevate the RR for an inpatient stay of ≥ 24 hours (RR 1.11, p = 0.001, both diagnoses). Stepwise multivariate analysis demonstrated significant predictors for inpatient stays of ≥ 24 hours to be an operation on L4-5, coexisting degenerative disc disease (DDD) with foraminal stenosis, and herniated nucleus pulposus (RR 1.11, 95% CI 1.03-1.20, p = 0.009, all covariates).

CONCLUSIONS

This study provides data regarding the incidence of demographic and perioperative characteristics and postoperative complications as they pertain to patients undergoing single-level ALIF. This preliminary investigation identified the most relevant risk factors to be considered before appropriately transitioning ALIF procedures to the ASC. Further studies of preoperative characteristics are needed to elucidate ideal ASC ALIF patients.

Risk Factors for Medical and Surgical Complications After Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion

Background

The prevention of perioperative and postoperative complications is necessary to avoid poor postoperative outcomes and increased costs. Previous investigations have identified risk factors for complications after various spine procedures, but no such study exists in a population solely undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The purpose of this study is to determine risk factors for the development of complications up to 2 years after MIS TLIF procedures.

Methods

Patients who underwent primary, single-level MIS TLIF from 2007 to 2016 were retrospectively reviewed. The incidence of medical and surgical complications up to 2 years postoperatively was determined. Patients were categorized according to demographic, comorbidity, and procedural characteristics. Bivariate Poisson regression with robust error variance was used to determine if an association existed between patient characteristics and complication incidence. A final multivariate model including all patient characteristics as controls was created using backwards, stepwise regression until only those variables with P < .05 remained.

Results

390 patients were analyzed. Upon bivariate analysis, age >50 years (P = .025), diabetes mellitus (P = .001), and operative duration >105 minutes (P = .016) were associated with increased medical complication rates. Regarding surgical complications, age ≤50 years (P < .001), obesity (P = .012), and diabetes mellitus (P = .042) were identified as risk factors on bivariate analysis. Upon final multivariate analysis, operative time >105 minutes (P = .009) and diabetes mellitus (P = .001) were independent risk factors for medical complications. Independent risk factors for surgical complications on multivariate analysis included age ≤50 years (P < .001), diabetes mellitus (P = .002), and obesity (P = .030).

Conclusions

Diabetic patients and those who underwent longer operations were at increased risk of medical complications, while younger patients, obese patients and those also with diabetes mellitus were at increased risk of surgical complications up to 2 years after MIS TLIF. Practitioners can use this information to identify patients who require preventative care before their procedure or increased postoperative vigilance and monitoring after single-level MIS TLIF.

Level of Evidence

3.

The identification of risk factors for increased postoperative pain following minimally invasive transforaminal lumbar interbody fusion

PURPOSE

To evaluate specific demographic and perioperative variables associated with higher inpatient pain scores following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

Patients who underwent a single-level, primary MIS TLIF were retrospectively reviewed. Perioperative outcomes were collected, and postoperative inpatient VAS pain scores were measured. Both bivariate and stepwise multivariate Poisson regressions with robust error variance were used to assess risk factors for average inpatient pain score ≥ 5.0. A final backward stepwise regression model was created using age, gender, smoking status, diabetes status, insurance status, BMI, comorbidity burden, pedicle screw laterality, operative time, and estimated blood loss.

RESULTS

A total of 255 patients undergoing primary, single-level MIS TLIF were included. Age less than 50 years, workers' compensation insurance, preoperative VAS pain score ≥ 7, and operative duration ≥ 110 min were associated with greater postoperative pain. However, other variables such as gender, BMI, smoking status, comorbidity burden, diabetes status, and pedicle screw laterality were not associated with increased postoperative pain.

CONCLUSION

The results of this study suggest that younger age, workers' compensation, elevated preoperative pain scores, and longer operative times are independently associated with greater inpatient pain following TLIF. Surgeons can use this information to better assess which patients may require additional pain control following TLIF. Patient expectations of postoperative outcomes in regard to pain and recovery may also be better managed. These slides can be retrieved under Electronic Supplementary Material. (paragraph). Then process the ppt slide as graphical image.

Evaluation of Postoperative Mental Health Outcomes in Patients Based on Patient-Reported Outcome Measurement Information System Physical Function Following Anterior Cervical Discectomy and Fusion

OBJECTIVE

To assess the relationship of preoperative physical function, as measured by Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF), to improvement in mental health, as evaluated by Short Form-12 Mental Component Summary (SF-12 MCS) following anterior cervical discectomy and fusion (ACDF).

METHODS

Patients undergoing primary ACDF were retrospectively reviewed and stratified based on preoperative PROMIS PF scores. PROMIS PF cohorts were tested for an association with demographic characteristics and perioperative variables using chi-square analysis and multivariate linear regression. Multivariate linear regression was utilized to determine the association between PROMIS PF cohorts and improvement in SF-12 MCS.

RESULTS

A total of 129 one- to 3-level ACDF patients were included: 73 had PROMIS PF < 40 ("low PROMIS") and 56 had PROMIS PF ≥ 40 ("high PROMIS"). The low PROMIS cohort reported worse mental health preoperatively and at all postoperative timepoints except for 1 year. Both cohorts had similar changes in mental health from baseline through the 6-month follow-up. However, at 1 year. postoperatively, the low PROMIS cohort had a statistically greater change in mental health score.

CONCLUSION

Patients with worse preoperative physical function reported significantly worse preoperative and postoperative mental health. However, patients with worse preoperative physical function made significantly greater improvements in mental health from baseline. This suggests that patients with worse preoperative physical function can still expect significant improvements in mental health following surgery.

The Relationship Between Preoperative PROMIS Scores With Postoperative Improvements in Physical Function After Anterior Cervical Discectomy and Fusion

OBJECTIVE

Assess preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) scores and differences between preoperative and postoperative PROMIS-PF scores for patients undergoing anterior cervical discectomy and fusion (ACDF).

METHODS

After Institutional Review Board approval, a prospectively maintained surgical registry was retrospectively reviewed for elective spine surgeries of nontraumatic, degenerative pathology between 2015-2018. Inclusion criteria were primary or revision, single-level ACDF procedures. Multilevel procedures and patients without preoperative surveys were excluded. A preoperative PROMIS score cutoff of 35 divided patients into PROMIS-PF score categories (e.g. , ≥ 35.0, < 35.0). Categorical and continuous variables were evaluated with chi-square tests and t-tests. Linear regression analyzed PROMIS-PF score improvement.

RESULTS

Eighty-six patients were selected, the high and low PROMIS-PF subgroups only differed in mean age (49.1 vs. 41.3, p = 0.002). Significant differences in PROMIS-PF scores were observed among high and low preoperative PROMIS-PF score subgroups at 6 weeks (p = 0.006), 12 weeks (p = 0.006), and 6 months (p = 0.014). Mean differences between preoperative and postoperative PROMIS-PF scores were significantly different between the high and low PROMIS-PF subgroups at 6 weeks (p = 0.041) and 1 year (p = 0.038). A significant negative association was observed between preoperative PROMIS scores and magnitude of improvement at the 6-week postoperative time point (slope = -0.6291, p < 0.001).

CONCLUSION

Patients with low preoperative PROMIS-PF scores demonstrated greater improvements at 6 weeks and 1 year. Clinicians should consider patients with low preoperative PROMIS-PF scores to be in the unique position to potentially experience larger postoperative improvement magnitudes than patients with higher preoperative PROMIS-PF scores.

The influence of gender on postoperative PROMIS physical function outcomes following minimally invasive transforaminal lumbar interbody fusion

PURPOSE

Our aim is to examine the gender performance of Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF) scores among patients undergoing minimally invasive transforaminal lumbar fusion (MIS TLIF).

METHODS

A prospectively collected surgical dataset was retrospectively assessed for eligible patients from March 2015-June 2019. We included patients if they underwent primary MIS TLIF procedures on one or two vertebral levels. We collected baseline demographics, perioperative characteristics, and PROMIS-PF scores for each subject at pre and postoperative timepoints (e.g., 6-weeks, 3-months, 6-months, and 1-year). Chi-squared analyses were utilized to assess categorical variables and a Student's t-tests analyzed continuous variables. A linear regression was used to analyze PROMIS-PF scores from baseline through all postoperative time points. Finally, we evaluated the PROMIS PF achievement of minimal clinically important difference (MCID) among gender.

RESULTS

192 patients were included: 77 were females and 115 were males. No significant differences were observed among gender subgroups for PROMIS-PF scores at pre- or postoperative evaluations. Compared to males, females experienced significantly greater postoperative improvement with PROMIS-PF scores at the 3-month assessments, though no significant gender differences were observed during later follow-up evaluations at 6-months or one year. Females were observed to have significant PROMIS-PF score improvement from their preoperative evaluation to each postoperative score. Males were assessed to have statistically significant postoperative (e.g., at 3-months, 6-months, and 1-year) PROMIS-PF score improvement from their preoperative PROMIS-PF scores. There were no significant differences among gender in achieving MCID at any postoperative time interval.

CONCLUSION

Among gender, we observed no statistically significant difference in PROMIS-PF scores during the pre- or postoperative evaluations. Additionally, with no difference in the rate of achieving PROMIS-PF MCID postoperatively, this study established that both genders should experience similar functional outcomes following MIS TLIF.

Subversion of host immune responses by otopathogens during otitis media

Otitis media (OM) is one of the most common ear diseases affecting humans. Children are at greater risk and suffer most frequently from OM, which can cause serious deterioration in the quality of life. OM is generally classified into two main types: acute and chronic OM (AOM and COM). AOM is characterized by tympanic membrane swelling or otorrhea and is accompanied by signs or symptoms of ear infection. In COM, there is a tympanic membrane perforation and purulent discharge. The most common pathogens that cause AOM are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis whereas Pseudomonas aeruginosa and Staphylococcus aureus are commonly associated with COM. Innate and adaptive immune responses provide protection against OM. However, pathogens employ a wide arsenal of weapons to evade potent immune responses and these mechanisms likely contribute to AOM and COM. Immunologic evasion is multifactorial, and involves damage to host mucociliary tract, genetic polymorphisms within otopathogens, the number and variety of different otopathogens in the nasopharynx as well as the interaction between the host's innate and adaptive immune responses. Otopathogens utilize host mucin production, phase variation, biofilm production, glycans, as well as neutrophil and eosinophilic extracellular traps to induce OM. The objective of this review article is to discuss our current understanding about the mechanisms through which otopathogens escape host immunity to induce OM. A better knowledge about the molecular mechanisms leading to subversion of host immune responses will provide novel clues to develop effective treatment modalities for OM.